End-Stage Renal Disease: Nutritional Considerations
Nutrition-related concerns include maintenance of acceptable weight and serum proteins (eg, albumin), prevention of renal osteodystrophy, and reduction of cardiovascular risk.
Weight Maintenance and Protein Requirements
Nutritional status should be assessed, and every patient with ESRD should receive a diet plan. ESRD patients on dialysis may spontaneously reduce protein and calorie intake as a result of uremic toxins, elevations in leptin and other cytokines, and delayed gastric emptying.10 The average energy intake of patients with ESRD is lower than the recommended 30 to 35 kcal/kg,11 and 50% of patients reveal evidence of malnutrition.12
To prevent malnutrition-related morbidity and mortality, ESRD patients on dialysis should have periodic nutrition screening, consisting of laboratory measures (eg, albumin), comparison of initial weight with both usual body weight and percent of ideal body weight, subjective global assessment, and dietary interviews with review of food diaries. Nutrition counseling should be intensive initially and provided every 1 or 2 months thereafter. If nutrient intake appears inadequate, malnutrition is apparent, or adverse events or illnesses threaten nutritional status, counseling should be increased. If protein-calorie needs cannot be met with the usual diet, patients should be offered dietary supplements or, if necessary, tube feeding or parenteral nutrition to approximate protein and calorie requirements.9
Sodium and Potassium Balance
A high-potassium diet is normally desirable to control blood pressure and reduce risk for stroke; however, individuals with ESRD on hemodialysis cannot tolerate this diet because they are unable to excrete potassium. Therefore, ESRD patients may need to avoid such foods as bananas, melon, legumes, potatoes, tomatoes, pumpkin, winter squash, sweet potato, spinach, orange juice, milk, and bran cereal to prevent life-threatening hyperkalemia-induced arrhythmia. Evidence indicates that the vast majority of patients comply with potassium restriction.1 In patients on peritoneal dialysis, hyperkalemia is significantly less likely and hypokalemia has been reported in some patients, at times requiring an increase in potassium-containing foods and even potassium supplementation.16
Certain other dietary supplements may be helpful. Supplementation with L-carnitine has been approved by the U.S. Food and Drug Administration to treat carnitine depletion in dialysis patients. In small studies L-carnitine has also been found to improve lipid metabolism, protein nutrition, antioxidant status, and anemia.23 However, some large studies have not confirmed these findings. Therefore, inadequate evidence exists to support the routine use of carnitine in patients who do not reveal signs of deficiency.24 Both vitamin C (250 mg/d) and vitamin E (400 IU/d) have proven effective in some patients for treating painful muscle cramps, and they provide a less toxic alternative to quinine therapy.25,26 However, additional clinical trials are required before these can be used as standard therapy.
Saturated Fat and Cholesterol
2-gram sodium, 2-gram potassium, phosphate-restricted diet, low in saturated fat and cholesterol.
Nutrition Consultation: To assess calorie and protein requirements, and instruct patient in above dietary recommendations.
B-complex with small doses of vitamin C, 1 tablet daily by mouth. Consider supplemental ergocalciferol or cholecalciferol.
What to Tell the Family
End-stage renal disease is often preventable with the proper control of blood pressure, blood lipids, and blood glucose, in combination with appropriate medications. For patients who have progressed to the need for dialysis, morbidity and mortality can be reduced and quality of life enhanced through adherence to an appropriate dietary and medical regimen, along with regular physical activity.
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